#94: Overuse Injuries Part 2 – The Shoulder Bone’s Connected to the Arm Bone!

September 27, 2023 | By Sam Masur

Audio

Summary:

Little league shoulder and gymnast’s wrist are extremely common diagnoses that can profoundly impact your patient’s training. Tune into this episode as Dr. Conde makes a comeback to walk us through the proper diagnosis and treatment of these overuse injuries.

Overuse Injury Pearls

1. Watch out for osteochondral dissecans lesions of the capitellum. These injuries can easily be misdiagnosed as overuse injuries as they can cause chronic elbow pain in overhead athletes. 
2. Differentiating between bone, tendon, and ligament injuries is hard. Pain with motion or resisted motion can often point to tendons or even bone injury. Laxity on exam points to ligament injury (this physical exam finding can take a while to get a sense for!) 
3. As pediatricians, we are often trained to avoid unnecessary imaging in kids. Don’t be afraid to get x-rays if your patient has multiple weeks of persistent pain or has failed initial conservative treatment!
4. Watch out for dorsal distal ulnar wrist pain. This is concerning for a TFCC ligament injury and will require an MRI to diagnose. 
5. It is uncommon for pediatric patients to tear their rotator cuff. Other pathologies, such as overuse, labral injuries, and rotator cuff tendonitis, are all commonly seen.

Overuse Injuries (Notes Pt. 2) 

Sports HPI

• Take a look at the show notes for Overuse Injuries part 1 to review sport’s medicine focused history of present illness! We won’t repeat it again here to save on space!

How to Master the MSK Exam

General Advice

• The only way to develop a good musculoskeletal exam is to build a system and examine a lot of patients.
• Always review the anatomy. There is no shame in taking out Netter’s or doing a quick internet search once you find out where the patient hurts. We do this all the time in the clinic and we see only Sports Medicine patients!
• Make a template in your note as a cheat sheet (depending on your EMR). This way you can remember some of those pesky special tests. Eventually you won’t even need your cheat sheet!
• Don’t rush to specific exam maneuvers to confirm your diagnosis– always do a complete exam. 
• Dr. Conde recommends the following standardized approach for every exam:
  • Inspection
  • Palpation
  • Range of Motion
  • Strength
  • Special Tests 

• We have included some broad highlights of the exam below, but it is by no means an exhaustive list of special tests and exam maneuvers. 

Wrist Exam

• Inspection: compare the injured wrist to the contralateral side. 
• Palpation: Push on the major bony landmarks including the distal radius and ulnar on both dorsal and volar surface. You should also palpate the scaphoid tubercle and the snuff box where the scaphoid lies. 
• Range of motion should be assessed and compared to the contralateral side. You should make sure to assess ulnar and radial deviation as well as flexion and extension. 
• Strength: should be tested for the major movements–extension, flexion, pronation, and supination. Additionally assess grip strength 
• Neurovascular: a complete wrist exam should include evaluating the motor and sensory components of the radial, ulnar, and median nerves. 
• Special tests: most of these are useful in diagnosing tendonitis (think the Finkelstein’s test) or carpal tunnel syndrome (think Tinel’s sign and Phalen’s maneuver). 

A word on Gymnast’s Wrist 

• Also known as distal radial apophysitis 
• It is most common in gymnasts (hence the name), but can occur in other sports involving upper extremity weight bearing. Think cheerleading! 
• An overuse injury that presents as non-traumatic distal wrist pain 
• The distal radial physis is more vulnerable during times of rapid growth (puberty)
• Patients may be anywhere between 8 and 15 years of age, but more common between 12 and 14. (Mauk et al., 2020) 
• Remember the ligaments surrounding a pediatric joint are stronger than the physis. Therefore it is often the physis that is injured. 
• Often caused by repetitive axial loading with the wrist in extension. This leads to ulnar overgrowth and altered mechanics that predispose the athlete to injury.  
• Physical exam will show tenderness over the volar aspect of the distal radius. The examiner can reproduce their pain by have them bear weight with an extended wrist. 
• Obtain an x-ray to check for widening of the physis. X-rays are often normal. 
• If physeal bridging if seen on x-ray, the patient should be referred to orthopedic surgery (Mauk et al., 2020)
• Treatment involves rest from weight bearing activity on the wrists until paint resolves.This usually takes at least 6 weeks. (Krabak and Brooks, 2023) 
• Athletes can still work on skills that do not require weight bearing 
• You can also help with pain relief by bracing or placing in a cast. Often gymnasts will require casting in order to prevent them from continuing their sport. 
• Physical therapy can be helpful to gradually return the athlete to play and work on proper biomechanics of the upper extremity. 
• Repeat x-ray in 6 months to 1 year is often helpful to monitor for physeal arrest. (Krabak and Brooks, 2023) 
• Watch out for pain localizing to the dorsal aspect of the distal ulnar wrist. The triangular fibrocartilage complex (TFCC) is located here and can be sprained or torn in athletes. This injury will not appear on x-ray and requires an MRI to diagnose. 

Shoulder Exam

• Pro-tip: when evaluating a shoulder make sure to also examine the scapula and neck. Often neck pain can be mistaken for shoulder pain. Don’t miss a neck injury presenting with shoulder pain! 
• Inspection/Palpation: You should examine 4 key areas: the anterior shoulder, posterior shoulder, acromioclavicular joint, and long head of the biceps. 
• Anterior view: inspect with the patient standing the anterior shoulder. Look for abnormal contours or prominences. Palpate the humeral head and physis. 
• Posterior view: inspect the posterior shoulder with the patient standing. Here you should focus on the position of the scapulae, and the muscles (deltoid, trapezius, infraspinatus/supraspinatus). Look for atrophy and asymmetry. 
• Acromioclavicular joint: palpate from the sternoclavicular joint down the clavicle to the AC joint noting tenderness, step offs, swelling, or spurs. 
• Long Head of Biceps: palpate the humeral head at the bicipital groove. 
• Range of motion: should be done standing. Have the patient actively flex, externally and internally rotate with both the arm at the side and at 90 degrees abduction, extend, and finally both abduct and adduct. 
• The rotator cuff (recall SITS from medical school – supraspinatus, infraspinatus, teres minor, and subscapularis) should be evaluated for its strength.
• Supraspinatus strength is tested with the arm in 90 degrees of abduction and 30 degrees of horizontal adduction. The arm should be internally rotated with the thumb pointing down/ .Have the patient resist downward pressure. This is known as the empty can test 
• Infraspinatus and teres minor can be evaluated with the arm placed at the side in neutral rotation with the elbow flexed to 90 degrees. Applying pressure on the forearm to internal rotate, the patient should resist. 
• Subscapularis can be evaluated multiple ways. The lift off test can be performed by having the patient place their hand behind their back with the palm facing away from the body. The patient should then push their hand away from the body against resistance. 
• Special tests: there are an infinite number of special maneuvers published for the shoulder. They largely do not relate to overuse injury and focus on impingement and tendinopathy diagnosis as well as joint instability. For the purposes of these notes we will hold off on diving into these deep oceans. 

A Word on Little League Shoulder

• Also known as proximal humeral epiphysiolysis 
• Most commonly seen in overhead athletes such as baseball or softball players who play year-round.
• Appears between the ages 11-16 
• Risk factors: include playing for multiple teams, non-adherence to pitch counts. 
• Pediatric athletes who are still skeletally immature should avoid breaking ball pitches to decrease their risk factors for overuse. 
• Presents as localized pain to the proximal humeral physis during the throwing motion. It may be asymptomatic otherwise.
• Physical exam is largely normal aside from tenderness to proximal humeral physis. 
• X-rays are often required to make the diagnosis. They will show widening of the proximal humeral physis laterally. It is often necessary to obtain a contralateral shoulder view in order to compare the physes. 
• Specific x-ray views to obtain: AP, Axillary, Y view. 

• Treatment requires rest from throwing for at least 6 weeks followed by 6 weeks of physical therapy and a return to throw program. (Zaremski et al., 2019)
• Risk of these injuries can be minimized by adhering to pediatric pitch counts. HERE is the most common guideline used. (https://www.mlb.com/pitch-smart/pitching-guidelines)
• Players should take at least 3 months per year off from pitching. 

When to Refer

• Higher level athletes with a specific activity (eg.: gymnastics).
• Help with Return-to-Play
• Specific needs like casting or splints 
• Patients who fail initial therapy 
• Consideration of more advanced imaging such as MRI or bone scan.

Goal

Listeners will explain the basic approach to diagnosis and management of overuse injuries of the upper extremity of pediatric patients  to improve the outpatient management of common sports injuries.. 

Learning objectives

After listening to this episode listeners will…  

1. Describe specific historical approach to upper extremity overuse injuries in pediatrics patients. 
2. Be familiar with the diagnostic approach for common wrist and shoulder sports medicine injuries.
3. Recognize what makes pediatric sports injuries and overuse injuries distinct from adult injuries.
4. Learn the basic treatment algorithm and approach to gymnast wrist and little league shoulder.

Disclosures

Dr. Conde reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Papakyrikos C, Ward B, Conde A, Masur S, Chiu C, Berk J. “#*94: Overuse Injuries Pt 2 – The Shoulder Bone’s Connected to the Arm Bone!”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ Sept 27, 2023.